腹胆管癌的微创切除是一种新兴技术，需要在微创肝切除和胆道重建方面都具备精湛的技术。由于胆胚血管解剖的技术困难、根治性门静脉淋巴结清扫以及胆肠吻合过程中需要进行细致缝合，即使在高级别肝脏外科中心，也一般不进行腹腔镜下的此类切除。现代文献中，缺乏关于该手术机器人技术的详细手术描述和结果数据。本视频展示了一例我们初期系列的纯机器人Klatskin 3A切除术，并附有临床结果。一名77岁男性出现黄疸，双侧肝内胆管扩张（右侧>左侧）的发现。放射学检查显示Klatskin 3A型肿瘤并伴有右前门静脉血栓形成。经胆道镜内窥镜检查进一步证实为高度Bismuth 3A型胆道恶性狭窄。通过放置两个15cm的7-French塑料内胆管支架实现内镜引流。三维解剖学肝脏重建显示右前部区域的Glissonean分段系脉有一个2cm的肿块，标准化的未来肝剩余体积（左肝叶）为50%。患者仰卧于手术台上，给予全身插管麻醉。在诊断性腹腔镜检查排除腹膜转移病的情况下，首先完成胆囊切除和系统性根治性门静脉淋巴结清扫以达到超过六个淋巴结的目标。经过适当的门静脉淋巴结清扫后，在胰头水平处隔离并切断了胆总管。取出塑料内胆管支架，对远端胆总管切缘进行了冻切，以排除胆管癌的远端侵犯。与主要门静脉旁边的小型右肝动脉一起用夹子结扎并切除，同时移除相邻的淋巴结和淋巴结带有的组织。如果冻切结果显示远端胆总管切缘未见肿瘤，可以缝合胰腺内部的远端胆总管。然后向肝门分叉处切取近端胆管，待胆管分叉已经适当解剖并从肝门板解脱后，在脐裂基部附近切断远端左肝管以获得R-0切缘。从左肝管切缘处取得第二个冻切标本，以确保未浸润肿瘤细胞存在于未来的胆管剩余侧。接着完成切断肝下短静脉。靛青绿注射后，确认肝实质切缘。结扎和夹闭右肝动脉和门静脉。使用机器人器械进行肝实质切缘线断开，使用机器人窗型双极钳和血管封闭装置进行压迫夹切技术。始终保留中肝静脉是为了避免左中肝叶的淤血。整个右肝叶和尾状叶被作为一个整块切除。打开肝脏后切断大的Makuuchi韧带，使用机器人血管夹钳切断右肝静脉的根部，与下腔静脉平齐。然后开始胆道重建，创建60cm乙状结肠的肝管空肠吻合吻合术。通过使用机器人45毫米蓝色扣钉器的两个动作来创建侧－侧的吻合术。并用连续缝合线合并吻合口。将乙状结肠肢后移，向肝门移位。使用连续可吸收的4-0镇定线进行单端-侧的肝管空肠吻合术。最后，在封闭之前放置了闭合式引流管。手术时间约为8小时，失血量约为150毫升。术后过程正常。最终病理报告证实，肝门部胆管癌为中度分化，切缘未见肿瘤。切除了10个淋巴结，未发现淋巴结转移或淋巴管血管侵犯。自2021年以来，我们已经对4名中位年龄为70岁的Klatskin 3A肿瘤患者进行了机器人切除。所有患者均表现为黄疸，大多数患者在术前接受内镜逆行胰胆管造影引流。中位手术时间为508分钟，估计失血量为150毫升。所有患者均获得了R-0切缘。有1名患者术后并发症需使用静脉抗生素治疗静脉系统感染。在此系列中未发现90天内的死亡。在中位随访期为15个月期间，所有患者都幸存，无疾病复发证据。机器人切除Klatskin 3A肿瘤在机器人肝胆外科手术经验适当的情况下是安全可行的，正如本视频所展示的。© 2023 Society of Surgical Oncology.

Minimally invasive resection for perihilar cholangiocarcinoma is an emerging technique that requires both mastery in minimally invasive liver resection and biliary reconstruction. Due to technical difficulties in biliovascular dissection, radical portal lymphadenectomy and the need for fine suturing during bilioenteric anastomosis, this type of resection is generally not performed laparoscopically, even at high-volume, liver-surgery centers.1-3 In modern literature, a detailed, operative description of robotic technique for this operation with outcome data is lacking. This video article demonstrates a pure robotic Klatskin Type 3A resection with clinical outcomes of our initial series.A 77-year-old man presented with jaundice and findings of bilateral, intrahepatic, ductal dilation (Right > Left). Radiological imaging showed a type 3A Klatskin tumor with associated thrombosis of the right, anterior portal vein. A further endoscopic evaluation with cholangioscopy confirmed a high-grade Bismuth 3A biliary malignant stricture. Endoscopic drainage was achieved with placement of two, 7-French, 15-cm, plastic, endobiliary stents. A 3-D anatomical liver reconstruction showed a 2-cm mass located in the area of right, anterior, sectoral, Glissonean pedicle with standardized, future, liver-remnant (left hepatic lobe) volume of 50%. The patient was placed supine on the operating table. General endotracheal anesthesia was administered. After exclusion of metastatic peritoneal disease with diagnostic laparoscopy, cholecystectomy and systematic radical portal lymphadenectomy were first completed with a goal to obtain more than six lymph nodes. After appropriate portal lymphadenectomy, the common bile duct was isolated and transected at the level of pancreatic head. The plastic, endobiliary stents were removed, and a distal common bile duct margin was sent for a frozen-section examination to rule out distal extension of the cholangiocarcinoma. A small, accessory, right, hepatic artery lateral to the main portal vein was ligated with locking clips and removed together with the adjacent nodes and lymphatic bearing tissues. The intrapancreatic portion of the distal common bile duct was suture closed once the distal common bile duct margin was confirmed to be negative for neoplasia by the frozen-section examination. The proximal bile-duct dissection commenced cephalad toward the hilar bifurcation. Once the biliary bifurcation has been adequately dissected and detached from the hilar plate, the distal, left, hepatic duct was then transected near the base of the umbilical fissure to gain an R-0 resection margin. A second frozen-section specimen was obtained from the left, hepatic duct cut edge to ensure an absence of infiltrating tumor cells on the future, bile-duct remnant side. Division of short, hepatic veins off the inferior vena cava (IVC) were next completed. Once the line of hepatic-parenchymal transection was confirmed by using indocyanine green administration, the right hepatic artery and portal vein were ligated and clipped. The liver, parenchymal transection began with a crush-clamp technique utilizing robotic, fenestrated bipolar forceps and a vessel-sealing device. Preservation of the middle hepatic vein is always the preferred technique to avoid congestion of the left medial sector of the liver. The entire right hepatic lobe and the caudate lobe were removed en bloc. A large, Makuuchi ligament was isolated and divided by using a robotic, vascular-load stapler once the liver is open-booked. Finally, the root of the right hepatic vein was exposed and transected flush to the IVC by using another load of robotic vascular stapler. The biliary reconstruction then began by creating a 60-cm, roux limb for a hepaticojejunostomy bilioenteric anastomosis. A side-to-side, stapled jejunojejunostomy was created by using two applications for robotic 45-mm, blue load staplers. The common enterotomy was closed with running barbed sutures. The roux limb was then transposed retrocolically toward the porta hepatis. A single end-to-side hepaticojejunostomy anastomosis was created with running absorbable 4-0 barbed sutures. Finally, a closed suction abdominal drain was placed before closing.The operative time was approximately 8 hours with 150 ml of blood loss. The postoperative course was unremarkable. The final pathology report confirmed a moderately differentiated perihilar cholangiocarcinoma with negative resection margins. Ten lymph nodes were harvested. No nodal metastasis or lymphovascular invasion was found. Since 2021, we have undertaken robotic resection of Klatskin 3A tumor in four patients with a median age of 70 years. All patients presented with jaundice, and they mainly underwent preoperative biliary drainage using ERCP. The median operative duration was 508 minutes with estimated blood loss of 150 ml. R-0 resection margins were obtained in all patients. One patient suffered from postoperative complications requiring treatment of line sepsis using intravenous antibiotics. We did not find a 90-day mortality in this series. At a median follow-up period of 15 months, all of the patients were alive without any evidence of disease recurrence.Robotic resection of Type 3A Klatskin tumor is safe and feasible with appropriate experience in robotic hepatobiliary surgery, as demonstrated in this video article.© 2023. Society of Surgical Oncology.